Surgery: Bilateral Medial Rectus Recession in a Patient with Esotropia and a Restrictive Component

This surgery demonstrates medial rectus recession in both eyes, patient had a restrictive component, and there was very little space underneath the muscles so a hook with a groove on it had to be used to make sure that the sclera was protected.

Transcript

DR WAGNER: Great. We just started doing a boy with congenital esotropia, bilateral esotropia. And we’re gonna recess the right and left medial rectus muscles.

>> How old is the boy?

DR WAGNER: That’s better. Okay. Okay. He also has a very… A somewhat tighter medial rectus muscle. I think that’s, again, related to a longstanding esotropia. He’s now… I’m not sure. How old is he now? 13 years old. Probably had this since birth. So I think you’ll often develop… You’re gonna hold it that way. And then I’d like to have the suture ready. It is long, right? What are you doing? Different needle? That’s okay. So here we have a number of blood vessels there. We could probably catch them with the locking bite, the second bite that I go through. Gonna go around. Come through the hole. And try to lock it. Should be locked. There we go. That’s a little shorter. This is a little better suture. Have the back end away from me. Thank you. I’ll grab it here.

>> Doctor, I know you’re in the middle of the procedure, but when you do have a second, we can’t see very well.

DR WAGNER: Okay. Could be my hand right there. But I’m holding it a certain way. How is that? Better?

>> Perfect. Thank you so much.

DR WAGNER: You guys keep an eye on that for me here. Let me know if we’re having trouble. Okay. I have to keep moving my hand. So I guess… It’s just where I am. I think after I do this one maneuver, we’re gonna be okay. Westcott scissor. Sorry. Disinsert it. And once again, I like to use small individual bites ’til I see where I am. And let’s take a look at the muscle. There we go. Looking at the monitor. Looks like we can see it. Good. Let’s clean it up a little bit. Can I have the cautery, please? So this is really hot cautery. So we just get it hot, take my finger off, and then use it. Might as well hit that one too. Okay. So… I’m gonna put the… Why don’t I do it a little bit different? I’m not gonna use the locking bite this time. I mean the locking forceps. I’m gonna use the regular forceps and show you how I do it this way. And that’s okay. I don’t need that. I need the caliper next. Actually, it’s a little bit easier with two-point fixation. So I will put one — one of the locks. But I’m gonna use one — if you’re doing it on your own, it’s a little easier to have the control — see what I’m doing? I like it — so I can lift it up. I can flatten the sclera. I can position it wherever I want a little bit easier. The one locking bite frees up my hand. So you don’t always have to use both. Good. And I measure from the posterior edge of the insertion.

>> So how many millimeters?

DR WAGNER: There is my mark. I like to enter… Get flat immediately, once I enter. You can dry that. Thank you. Let go. And I’ll reposition. So you don’t have to worry about it. That’s a good depth. That’s good. My other mark might be gone. So I’ll re-mark it again.

>> Can you tell us the deviation of the patient?

DR WAGNER: What was the question?

>> What’s the deviation?

DR WAGNER: Oh, okay. Yeah. I usually don’t do more than 6.5 anyway. I maybe have done some 7s in rare cases. But I don’t like to do more than that. Once I have it in the sclera, I just keep the tip very, very flat. More up than down. You certainly don’t want to go any deeper. I try to make a long track here, if I can. That looks pretty good. Let’s see where it is. It’s spread pretty nicely. There’s a little dam there. We’ll get rid of that. That looks good. So let me… We’ll cut one of these. So, you see, the exit point is not as important as the entry point. I’m not exactly exiting even with each other — but that’s okay. It’s all a matter of where you enter the sclera. Because that’s where the muscle will be, when you pull it up. Needle. Right there. She’s got the needle, right? She took it. She did it. And when you tie the first knot, you have to get it flat. So if you can’t get it — you don’t like your positioning, just go close, and then just get it tight in that spot. Regrab it closer to the knot. You don’t want to grab too far away, because you can rip it. And then the second knot has to be — you can’t disturb the first. So I’m gonna do all my tying in the air up here. And don’t do anything until I get right to the very, very last — right over the knot. Like this. And now I’m gonna regrab it, because I want to make sure I get it tight. So I’ll take it here and here. And cinch it really tight right there, like that. Okay. And cut. There’s the needle. Can I have another forceps? Plain suture coming up. Gonna move that. That looks nice. That’s where I want it. Sometimes I release the tension a little bit. So it’s more normal position. Long lashes. What I’m gonna have you do… Hold those up there like that. Good. I can see it better. You can cut that. I usually don’t attach it exactly up all the way to the limbus, because it’s gonna get there anyway, when we tie it. Because the eye is really adducted now. Abducted. Excuse me. You’ll see what I mean.

>> Can you say it again?

DR WAGNER: What I was saying is that where I entered, I didn’t go all the way — exactly all the way up to the limbus, because I know — I don’t want it to overhang on the cornea. You’ll see. When I go to the straight-ahead position, you’ll see. It’ll be where we want it to be. I got jammed up here. A piece of suture in there. Okay. That’s good. I’ll bring it down this way. There’s a nice long suture. Yeah. Let me get the needle. Then we’ll cut — we’ll need a little bit more suture than this, but not nearly as much as we have here. So how much… I’m gonna do three more closures. So if we go to about there, I think, it should be enough. Good. And, again, you never want to close — like, when you look sometimes, quickly, you’re not sure. And if you grab it, you might grab here. Well, that’s the plica or the semilunar fold, and that would be bad, because it would give you a lot of scarring when you do that. So I’ve got to find the edge of the conj. And usually it’s easily recognizable.

>> It looks like Tenon’s.

DR WAGNER: Like here. We’re good here. And what I’ll do is I’ll show you how we check for the Tenon’s capsule, after I close this. We just put a little BSS on there. And if there’s Tenon’s, it fluffs it up. If not, it… Just looks the same. By the way, when you assist somebody, like — don’t cut it yet. Don’t cut it yet. When you assist somebody, the best thing to do is to lift the sutures up, bring them toward you a little bit, to give the surgeon a very good view, or whoever’s gonna cut it a very good view of it. Go ahead. You cut now. Good. Now… Let me have the BSS. Let’s just try… Let’s wet it with the BSS. See what happens. No Tenon’s here. So you want to infuse that? Do we have the infusion of the… We could put the marcaine in there. Let’s do it now. Then we won’t have to go back to that eye. Good. Then I won’t have to go back to that eye. Is that a needle?

>> It’s a needle.

DR WAGNER: We don’t really want a needle. I think maybe something like… Like this would be nice. We’re gonna infuse a little bit of marcaine in there. And I don’t want to use a needle, a blunt, a sharp needle. It makes no sense. Because all we want to do is get it retro — peribulbar area. And you could do it at the end of the case, but since I’m here on this eye, I might as well just do it. How long does the marcaine — we think it lasts? 4 to 6 hours? So yeah. I’ll put some over here too. A nicer hole there. Good. Okay. So we can take this out. I don’t think that’s Tenon’s, is it? Oh yeah. I don’t think that’s Tenon’s there, is it? I might have to do something with that. We’re injected. What I’m looking at — I’m looking at that little cystic area there. And I don’t know if that’s just a conj cyst — I think it is. I think it’s just where the injection was given. I don’t think it’s prolapse of the Tenon’s capsule. I’m not sure now. See? It’s from the injection… I just want to see. I want to check it. From the injection. There’s a little Tenon’s. I’m gonna cut it out. Maybe it was a good thing. Because I might have had that there and didn’t really notice it, until I gave the injection. So this is what I was talking about, how the Tenon’s capsule fluffs up, and that’s how you know whether you have a… That looks better. So that’s good. And the other thing I want to show you is: The conjunctiva here — this is what I was talking about. It’s just about up to the limbus, but it’s not over the limbus. So I attached it a little bit farther back than bringing it all the way up. Because sometimes if you get it too close, it’ll be overlapped. Especially if you’re doing a resection. If you’re doing a resection, that’s not good, because sometimes you get too much tissue there. And you get, like, a dellen formation. Anywhere there’s an elevation near the limbus, you can get a dry spot on the cornea next to it. That’s called a dellen. And that can be painful. Get those lashes out of there. That’s better. So now we’re gonna adjust the light a little bit. On to the left eye. That was the right one. And do you prefer to sit right where you are, Dr. Phan? Good. So now we’re just gonna do the exact same procedure on the right eye. So I’m gonna talk like I’m an assistant, so that you can see what we need to do as an assistant. And I’m gonna help her now by pulling the eye down a little bit, so that she can see the superior limbus a little bit better. I’m gonna get a clamp. Okay. I have it. We’ll clamp it. Let it hang down. You don’t have to really clamp it to anything. Just let it hang down. I think the problem… See, maybe this would be a case where a blade would be better. But let me try something. Yeah. They’re really long. I guess you could put tape on it. But you could… I don’t like those lashes. Yeah, let’s put a Steri-Strip on there. These are really long lashes. This is a male, right? See, women would really like those lashes.

>> You’re just jealous.

DR WAGNER: Hold that. Yeah. So why do you think I’m unusual? Oh, that’s very unusual. I see. Let’s try that. Let’s see if this works. If we bring his lid back — yeah, that’s it. Oh yeah. Now put the speculum back in, and we’re gonna be fine, I think. I think that’s okay, right? Yeah. That’s good. Better. Because you can’t avoid them. You’re gonna cut them if you try to… If they’re there. They’re just in the way. That’s good. I’m gonna reach under here, and I’m gonna do this to help you a little bit. I’m gonna pull it over a little more. So you can have better exposure. When I was doing my fellowship, at the Wills Eye Hospital in Philadelphia, the professor, Dr. Calhoun, who was one of the original doctors that used to go on Orbis, said he would train us to be assistants. And he would say: Okay. He would say — let’s start the case. I know nothing about what I’m doing here. You tell me exactly everything that I have to do, and I’ll do whatever you say. And it was a good learning experience. There’s a lot of tissue there. So what you want to do is keep the tip down like this, but slide it more. Okay? Just do it again. Let me try something. That’s better, right? Yeah. I think you got it out of there. Keep the tip down again. Just a little bit more, just to make sure. Let me feel how it feels. You can tell by the way it feels. That feels good. If you’re not sure — here’s a maneuver you want to do. If you’re not sure, lift up, slide it a little bit more, exaggerate it a little bit more. Usually you’ll have all of that. Usually. I think we have all of that. It’s tight. So let me try with the small hooks. You hold it flat toward you. I’m gonna bring it up this way. This doesn’t look 100% right. Yeah, the muscle’s a little — I see. You see it? So let’s see. So what do we want to trim? A little bit of this Tenon’s here. Now, in this case, now, since we don’t see where the muscle is, do exactly what you’re doing. Start a little higher, and see where everything is. Okay? Until we’re sure that we have muscle tissue. So I think it’s just bunched a little bit in the clamp. Either that, or there could be a little bit over here. So let’s try something else. Let me have another large hook. Go from the other side. This is what you do. You just take your time and make sure where everything is. I think that’s pretty good. That’s better, I think. Right? Okay. So… So now let’s do it this way, with a cotton tip, just to make sure we have everything. Pull it tight toward you. Okay? And I’m gonna lift up this connective tissue. Okay. Keep it this way toward you. There’s a little more — can I have the other small hook, please, again? And… You can use the Westcott. Dr. Phan, use the Westcott. And she’s gonna trim that. And this is connective tissue there. So this is what I say — these kids that have this infantile esotropia, congenital esotropia, for a long time — I think this is what happens. They get a lot more connective tissue around there, and sometimes it’s just really hard to isolate it and to see where everything is. I think that’s good. Okay. I’ll hold it for you, for a second, while they get everything ready. Getting the vicryl ready for Dr. Phan? Yeah. So if I want to help her now, you have a choice. You could either hold this suture, this, in your hand, if you want, or maybe pull that toward you. That might be easier. Gives you better visualization. I’m sliding the hook back a little bit, so she can see better. Okay. Let me help here. Wait a minute. Wait a minute. Wait a minute while I get that out of there. Now, in this case, if you… There you go. I want you to see the opening. Keep advancing it. Very good. It’s in the loop. It’s gonna lock. Very good. Let me dry this for you a little bit so you can see a little better.

>> So why don’t you use the hook with the groove on it?

DR WAGNER: Excuse me?

>> Why don’t you use the hook with the groove on it?

DR WAGNER: The groove? Oh, the hook with the groove that I used the other day was because it was so tight that I couldn’t get enough space to put the suture through there. But you could use it on every case, to be honest with you. I mean, it’s just… You don’t always need it. There’s times when you really need it. But I don’t think in this case we really need it. I think we could work around it. But you’re right. It’s a pretty good instrument, when you need it.

>> Okay, thank you.

DR WAGNER: I find it most useful in cases of thyroid ophthalmopathy, where you have a very tight muscle, or, like, a restrictive strabismus, like we had. That type of stuff. Let me dry it. Always dry it before you cut. Make sure you can see. Okay, good. Let’s check the muscle. Muscle is spread nicely. Good. Looks good. Yeah. First I want you to cut a little bit of this off, though. Wait a minute here. Let’s cut it. Get the cautery, I guess. No, cut those first, I guess. Cut a little bit more of that off. Good. That’s good. Now I want the cautery. So I’m gonna — what I’m gonna do — I’m gonna hold these on here for you, for a second. Press. Let you get everything ready. And when I take it off, I’ll take it off a little bit there. Good. Good. Let’s see. Where is it going from? Here? Maybe over here a little bit? Sorry. Get that vessel there. That squiggly vessel there. And right over here. Good. Okay. That’s pretty good. So let’s put the locking forceps on. You want to try that? Where you hold one? Because you like to hold, right? So probably… I don’t know which one’s easier to do it with. You’re gonna do — which one are you gonna do first? You’re gonna do the upper one or the other one? So let’s say you do the lower one, okay? So then it’s better to put this one on the lower one, because you grab from the upper, and then you’re pushing toward your hand, which is better. Excuse me. So we’ll leave one here. And I’m gonna give her another forceps in her right hand. Okay, good. Over here. Wait a minute. Good. That should be — we can always mark it again, if we have to. Make sure we have that lower one. Okay, good. So you get ready. You’re gonna use this one in your hand. Okay? And, see, the locking forceps — they vault over the cornea. They don’t hit the cornea. Because if you have a straight one, you’ll have trouble. Let me mark it again for you. Can you see it? Okay. I don’t know. That seems a little… Let me mark it again. I think that’s it. A little bit more. That’s good. Very good. That’s good. Very nice. That’s perfect. A little bit more. A little more. Okay. Good. And the other one’s gonna go over here. So this time I’m going to switch this. Put this here. Get out of there. Bring it over. Let me position that for you a little bit better. Sorry. Let me get this suture out of the way. And find the other edge. Like… There to there. That looks good. Good. That’s good. And then you can hold this one. When you get it loaded up. You have one. Okay? Good. Now, let me dry that for you. Make sure you see it. Good. And don’t press down too much. Wait. Before you do it — I’m sorry. Do it again, but what I want you to do is, when you grab it, don’t press. Lift up a little bit. And then, when you lift up, it makes the sclera nice and flat. And then you can see it. Let me dry this. Let me get the field clear. So you can see what you need to do. Hold on. Let me go back a little bit more this way. Okay? Good. Very good. I’m gonna bring it toward you a little bit more. That’s good. You’re fine. Don’t lift too much, now, because that sclera is a little — that’s good. A little bit more. Now, don’t turn it too much. That’s good. Just get flat. That’s it. When you grab it — you grabbed it perfectly. Just nice and flat. So that it doesn’t rotate. Didn’t like something? Oh, you didn’t want to hit the other suture? Yeah. Good. Yeah, good. Good. I’ve seen those cut before. You know that? Yeah. In fact, some people, what they do — some people leave the needle in. In other words, they leave — they put one needle in. If they really want to cross them — they call it crossed swords — if you really want to cross it like that, you leave one needle in the sclera. And then this way you can’t cut it with the other needle. You’ll just hit it. But I don’t really recommend that you need to do that. That couldn’t be done. Okay. So we’re gonna cut one of those sutures for her. We need a Westcott. You’re right. You wanna cut one? Okay. You’ve got it right here. Right above my instrument. There we go. Okay. Okay. I’ll do what I did… Get it closer and bring it up, slide it down… That’s good. Cut it a little long. Because it’s gonna be covered by the conjunctiva. And it’s safe that way. Can I have the cautery, please, again? I like the tray set like this, because I like to reach over sometimes and just grab something. You know what I mean? It’s good to… Yeah. Gotta laugh. Okay, good. Plain suture. What’s left of it. Gonna reach over here. Try to divide it up the best way you can. That’s it. Yeah. Grab it — that’s better. That’s perfect. Yeah, good. So keep that one in your hand like that. So give her the suture. So this is a very good technique, I think. If some people want — you can use a fornix incision or a limbal incision. There’s not much difference, as far as the ultimate result. Sometimes you need to do a limbal, because of scarring on reoperations. You need to know how to do it. But, you know, it’s a personal preference, in many cases. I think that’s gonna be pretty good there. Yeah. That’s good. Get that in. That little infusion. The marcaine. Okay. We’re just about done. We’re gonna infuse a little bit more of that marcaine in there. There you go. Try to find a hole where it goes right in. You know? Go pretty far. The farther you go, the better off, as long as you’re not into anything. That’s good. More marcaine going in. The anesthesiologist likes marcaine. Yeah. You know, the interesting thing about marcaine — I’m sure the doctor knows this — if you inject it into the muscle, it causes fibrosis. And that’s why people stopped doing many retrobulbars. Because they would hit them. Now, Dr. Scott, the inventor of Botox, has decided to take advantage of this, and he’s using marcaine into the muscle to strengthen or constrict the muscle, if you want to get more effect — tighten it. And it seems to be possibly working, for certain things. Tried it for convergence efficiency, which is a condition where people look up close, and their eyes go out. And the medial rectus muscle is usually a little bit weaker. So they’ve tried to just inject one medial rectus muscle with marcaine, and it seems to be somewhat effective. It takes time, though, because it takes a few weeks for the fibrosis to happen. And to make it really complicated or interesting, sometimes they inject the lateral muscle with Botox, and the medial muscle with marcaine, and so that during the time when the Botox is making the eye turn in, the marcaine has a chance — I mean the fibrosis has a chance to occur, and then it causes a fibrosis and pulls it in. So it’s just interesting. And we were saying… Is that really necessary? I said — well, people laughed when he invented Botox. And look what happened there. Not just for eyes, but for a lot of things. So you never know. Right? Something could result from this.